Peripheral joints

Look

The first principle is always to compare right with left. Remember that joints are three-dimensional structures and need to be inspected from the front, the back and the sides. The skin is inspected for erythema indicating underlying inflammation and suggesting active, intense arthritis or infection, atrophy suggesting chronic underlying disease, scars indicating previous operations such as tendon repairs or joint replacements, and rashes. For example, psoriasis is associated with a rash and polyarthritis (inflammation of more than one joint). The psoriatic rash consists of scaling erythematous plaques on extensor surfaces. The nails are often also affected (page 252). Also look for a vasculitic skin rash (inflammation of the blood vessels of the skin), which can range in appearance from palpable purpura or livedo reticularis (bluish-purple streaks in a net-like pattern) to skin necrosis.

A small, firm, painless swelling over the back (dorsal surface) of the wrist is usually a synovial cyst—a ganglion.^c A larger, localised, soft area of swelling of the dorsum of the wrist generally indicates tenosynovitis.

Note any swelling over the joint. There are a number of possible causes: these include effusion into the joint space, hypertrophy and inflammation of the synovium (e.g. rheumatoid arthritis), or bony overgrowths at the joint margins (e.g. osteoarthritis). It may also occur when tissues around the joints become involved, as with the tendinitis or bursitis of rheumatoid arthritis. Swelling of the lower legs may be due to fluid retention, which is painless and can occur in association with inflammation anywhere in the leg. Painful swelling may result from inflammation of the ankle joints or tendons, or of the fascia, or from inflammatory oedema of the skin and subcutaneous tissue.

Deformity is the sign of a chronic, usually destructive, arthritis, and ranges from mild ulnar deviation of the metacarpophalangeal joints in early rheumatoid arthritis to the gross destruction and disorganisation of a denervated (Charcot’s^d) joint (Figure 10.20, page 319). Deviation of the part of the body away from the midline is called valgus deformity, and towards the midline, varus deformity. For example, genu valgum means knock-kneed and genu varum, bow-legged.

Look for abnormal bone alignment. Subluxation is said to be present when displaced parts of the joint surfaces remain partly in contact. Dislocation is used to describe displacement where there is loss of contact between the joint surfaces.

Muscle wasting results from a combination of disuse of the joint, inflammation of the surrounding tissues and sometimes nerve entrapment. It tends to affect muscle groups adjacent to the diseased joint (e.g. quadriceps wasting with active arthritis of the knee) and is a sign of chronicity.

Feel

Palpate for skin warmth. This is done traditionally with the backs of the fingers where temperature appreciation is said to be better. A cool joint is unlikely to be involved in an acute inflammatory process. A swollen and warm joint may be affected by active synovitis (see below), infection (e.g. Staphylococcus) or crystal arthritis (e.g. gout).

Tenderness is a guide to the acuteness of the inflammation, but may be present over the muscles of patients with fibromyalgia. The patient must be told to let the examiner know if the examination is becoming uncomfortable. Tenderness can be graded as follows:

This may result from joint inflammation or from lesions outside the joints (periarticular tissues), including inflamed tendons, bursae, or attachments (entheses). Infected joints are extremely tender and patients will often not let the examiner move the joint at all. Palpation of a joint or area for tenderness must be performed gently, and the patient’s face rather than the joint itself should be watched for signs that the examination is uncomfortable.

Palpate the joint deliberately now, if possible, for evidence of synovitis, which is a soft and spongy (boggy) swelling. This must be distinguished from an effusion, which tends to affect large joints but can occur in any joint. Here the swelling is fluctuant and can be made to shift within the joint. Bony swelling feels hard and immobile, and suggests osteophyte formation or subchondral bone thickening.

Move

Much information about certain joints is gained by testing the range of passive movement. (Passive movement is obviously contraindicated in cases of recent injury to the limb or joint, such as a suspected fracture.) The patient is asked to relax and let the examiner move the joint. This must be attempted gently and will be limited if the joint is painful (secondary to muscle spasm), if a tense effusion is present, if there is capsular contraction or if there is a fixed deformity. The joints may have limited extension (called fixed flexion deformity) or limited flexion (fixed extension deformity). Passive movement of the spine is not a practical manoeuvre (unless the examiner is very strong), and active movement is tested here. Active movement is more helpful in assessing integrated joint function. Hand function and gait are usually applied as tests of function. Pain on motion indicates a joint or periarticular problem.

Stability of the joint is important and depends largely on the surrounding ligaments. This is tested by attempting to move the joint gently in abnormal directions to its usual limits, set by ligaments and muscular tone.

Joint crepitus, which is a grating sensation or noise from the joint, indicates irregularity of the articular surfaces. Its presence suggests chronicity.

Measure

Accurate measurement of the range of movement of a joint is possible with a goniometer, which is a hinged rod with a protractor in the centre. The jaws are opened and lined up with the joint. Measurement of joint movements is performed from the zero starting position. For most joints this is the anatomical position in extension—e.g. the straightened knee. Movement is then recorded as the number of degrees of flexion from this position. A knee with a fixed flexion deformity may be recorded as ‘30 to 60 degrees’, which indicates that there is 30 degrees of fixed flexion deformity and that flexion is limited to 60 degrees. At some joints both flexion and extension from the anatomical position can be measured, as at the wrists. The goniometer is not routinely used by non-rheumatologists and there is a wide range of normal values for joint movement. Most clinicians estimate the approximate joint angles.

A tape measure is useful for measuring and following serially the quadriceps muscle bulk and in examination of spinal movements.

The hands and wrists (Figures 9.5 to 9.9)

Examination anatomy

The articulations between the phalanges are synovial hinge joints. The eight bones of the wrist (carpal bones) form gliding joints which allow wrist movements—flexion/extension and abduction/adduction as they slide over each other.

Figure 9.5 Examination of the hands and wrists

Sitting up (hands on a pillow)

1. General inspection

Cushingoid

Weight

Iritis, scleritis, etc

Obvious other joint disease

2. Look

Dorsal aspect

• Wrists

Skin—scars, redness, atrophy, rash

Swelling—distribution

Deformity

Muscle wasting

• Metacarpophalangeal joints

Skin

Swelling—distribution

Deformity—ulnar deviation, volar subluxation etc

• Proximal and distal interphalangeal joints

Skin

Swelling—distribution

Deformity—swan necking, boutonnière, Z, etc

• Nails

Psoriatic changes—pitting, ridging, onycholysis, hyperkeratosis, discoloration

3. Feel and move passively

Wrists

• Synovitis

• Effusions

• Range of movement

• Crepitus

• Ulnar styloid tenderness

Metacarpophalangeal joints

• Synovitis

• Effusions

• Range of movement

• Crepitus

• Subluxation

Proximal and distal interphalangeal joints

• As above

Palmar tendon crepitus

Carpal tunnel syndrome tests

Palmar aspect

• Skin—scars, palmar erythema, palmar creases (anaemia)

• Muscle wasting

4. Hand function

Grip strength

Key grip

Opposition strength

Practical ability

5. Other

Elbows—subcutaneous nodules—psoriatic rash

Other joints

Signs of systemic disease

Figure 9.6 (right) X-ray of normal hand

Courtesy M Thomson, National Capital Diagnostic Imaging, Canberra.

Figure 9.7 Rheumatoid arthritis, early findings

X-ray of the hands of a patient with early rheumatoid arthritis. Note erosions of the heads of the metacarpophalangeal joints and of the ulnar styloid, and reduced amounts of cartilage in the joint spaces.

Courtesy Canberra Hospital X-ray library.

Figure 9.8 Rheumatoid arthritis, late findings

X-ray of the hands of a patient with advanced rheumatoid arthritis. Note loss of joint space and destruction of the right carpal joints, subluxation of metacarpophalangeal and poximal interphalangeal (PIP) joints, and Z deformity of the thumb. There are erosions of the PIP joints, a sign of active disease.

Courtesy Canberra Hospital X-ray library.

Figure 9.9 Osteoarthritis arthritis

X-ray of the hands showing the typical findings of osteoarthritis with joint-space narrowing and proliferative changes in the distal joints. Also note erosive and destructive changes at multiple proximal interphalangeal joints.

Courtesy Canberra Hospital X-ray library.

Look

Start the examination at the wrists and forearms. Inspect the skin for erythema, atrophy, scars and rashes. Look for swelling and its distribution. Next look at the wrist for swelling, deformity, ulnar and hyloid prominence. Then look for muscle wasting of the intrinsic muscles of the hand. This results in the appearance of hollow ridges between the metacarpal bones. It is especially obvious on the dorsum of the hand.

Go on to the metacarpophalangeal joints. Again note any skin abnormalities, swelling or deformity. Look especially for ulnar deviation and volar (palmar) subluxation of the fingers. Ulnar deviation is deviation of the phalanges at the metacarpophalangeal joints towards the medial (ulnar) side of the hand. It is usually associated with anterior (Volar) subluxation of the fingers (Figure 9.10). These deformities are characteristic but not pathognomonic of rheumatoid arthritis (Table 9.9).

Figure 9.10 The hands in rheumatoid arthritis

TABLE 9.9 Differential diagnosis of a deforming polyarthropathy

Rheumatoid arthritis

Seronegative spondyloarthropathy, particularly psoriatic arthritis, ankylosing spondylitis or Reiter’s disease

Chronic tophaceous gout (rarely symmetrical)

Primary generalised osteoarthritis

Erosive or inflammatory osteoarthritis

Next inspect the proximal interphalangeal and distal interphalangeal joints. Again note any skin changes and joint swelling. Look for the characteristic deformities of rheumatoid arthritis. These include swan neck and boutonnière deformity of the fingers and Z deformity of the thumb (Figure 9.10). They are due to joint destruction and tendon dysfunction. The swan neck deformity is hyperextension at the proximal interphalangeal joint and fixed flexion deformity at the distal interphalangeal joint. It is due to subluxation at the proximal interphalangeal joint and tendon shortening at the distal interphalangeal joint. The boutonnière (buttonhole) deformity consists of fixed flexion of the proximal interphalangeal joint and extension of the distal interphalangeal joints. This is due to protrusion of the proximal interphalangeal joint through its ruptured extensor tendon. The Z deformity of the thumb consists of hyperextension of the interphalangeal joint and fixed flexion and subluxation of the metacarpophalangeal joint.

Now look for the characteristic changes of osteoarthritis (Figure 9.11). Here the distal interphalangeal and first carpometacarpal joints are usually involved. Heberden’s nodes^e are a common deformity caused by marginal osteophytes that lie at the base of the distal phalanx. Less commonly, the proximal interphalangeal joints may be involved and osteophytes here are called Bouchard’s^f nodes.

Figure 9.11 The hands (a) and the feet (b) of a patient with osteoarthritis

Showing Heberden’s nodes (distal interphalangeal joints), Bouchard’s nodes (proximal interphalangeal joints) and bunions.

Look also to see if the phalanges appear sausage-shaped. This is characteristic of psoriatic arthropathy, but can also occur in patients with Reiter’s disease. It is due to interphalangeal arthritis and flexor tendon sheath oedema. Finger shortening due to severe destructive arthritis also occurs in psoriatic disease and is called arthritis mutilans. The hand may take up a main en lorgnette (‘hand holding long-handled opera glasses’) appearance due to a combination of shortening and telescoping of the digits.

Now examine the nails. Characteristic psoriatic nail changes may be visible: these include pitting (small depressions in the nail), onycholysis (Figure 9.12) and, less commonly, hyperkeratosis (thickening of the nail), ridging and discoloration. The presence of vasculitic changes around the nailfolds implies active disease. These consist of black to brown 1–2 mm lesions due to skin infarction and occur typically in rheumatoid arthritis (Figure 9.13). Splinter haemorrhages may be present in patients with systemic lupus erythematosus (and infective endocarditis) and are due to vasculitis. Unlike nailfold infarcts they are located under the nails in the nail beds. Periungual telangiectasiae occur in systemic lupus erythematosus, scleroderma or dermatomyositis.

Figure 9.12 Psoriatic nails

Showing onycholysis and discoloration, with typical pitting and ridging.

Figure 9.13 Rheumatoid vasculitis (arrows)

The hands should now be turned over and the palmar surfaces revealed. Look at the palms for scars (from tendon repairs or transfers), palmar erythema, and muscle wasting of the thenar or hypothenar eminences (due to disuse, vasculitis or peripheral nerve entrapment). Telangiectasia here would support the diagnosis of scleroderma.

Feel and move

Turn the hands back again to the palm-down position. Palpate the wrists with both thumbs placed on the dorsal surface by the wrists, supported underneath by the index fingers (Figure 9.14). Feel gently for synovitis (boggy swelling) and effusions. The wrist should be gently dorsiflexed (normally possible to 75 degrees) and palmar flexed (also possible to 75 degrees) with the examiner’s thumbs. Then radial and ulnar deviation (20 degrees) is tested (Figure 9.15). Note any tenderness or limitation of movement or joint crepitus. Palpate the ulnar styloid for tenderness, which can occur in rheumatoid arthritis.

Figure 9.14 Palpating the wrist joint—approved method

Figure 9.15 Movements of the wrist

(a) Ulnar and radial deviation. (b) Dorsal and palmar flexion.

Test for tenderness at the tip of the radial styloid. This suggests de Quervain’s^g tenosynovitis.

Feel for tenderness in the anatomical snuff box if scaphoid injury is suspected (Figure 9.15). Test for tenderness distal to the head of the ulna for extensor carpi ulnaris tendinitis.

Go on now to the metacarpophalangeal joints, which are palpated in a similar way with the two thumbs. Again passive movement is tested. Volar subluxation can be demonstrated by flexing the metacarpophalangeal joint with the proximal phalanx held between the thumb and forefinger. The metacarpophalangeal joint is then rocked backwards and forwards (Figure 9.16). Very little movement occurs with this manoeuvre at a normal joint. Considerable movement may be present when ligamentous laxity or subluxation is present.

Figure 9.16 Examination for volar subluxation at the metacarpophalangeal joints

Palpate the proximal and distal interphalangeal joints for tenderness, swelling and osteophytes.

Next test for palmar tendon crepitus. The palmar aspects of the examiner’s fingers are placed against the palm of the patient’s hand while he or she flexes and extends the metacarpophalangeal joints. Inflamed palmar tendons can be felt creaking in their thickened sheaths and nodules can be palpated. This indicates tenosynovitis.

A trigger finger may also be detected by this manoeuvre. Here the thickening of a section of digital flexor tendon is such that it tends to jam when passing through a narrowed part of its tendon sheath. Rheumatoid arthritis is an important cause. Typically, flexion of the finger occurs freely up to a certain point where it sticks and cannot be extended (as flexors are more powerful than extensors). The application of greater force overcomes the resistance with a snap.

If the carpal tunnel syndrome is suspected, ask the patient to flex both wrists for 30 seconds—paraesthesiae will often be precipitated in the affected hand if the syndrome is present (Phalen’s^h wrist flexion test). The paraesthesiae (pins and needles) are in the distribution of the median nerve (page 363), when thickening of the flexor retinaculum has entrapped the nerve in the carpal tunnel (Table 9.10). This test is more reliable than Tinel’s sign,ⁱ in which tapping over the flexor retinaculum (which lies at the proximal part of the palm) may cause similar paraesthesiae.⁴

TABLE 9.10 Causes of carpal tunnel syndrome

Occupation-related: working with wrists and hands flexed Rheumatoid arthritis Hypothyroidism Acromegaly

Pregnancy

Gout

Obesity

Amyloidosis

Diabetes mellitus

Idiopathic

Carpal bone osteomyelitis

Now test active movements. First assess wrist flexion and extension as shown in Figure 9.17. Compare the two sides. Now go on to thumb movements (Figure 9.18). The patient holds the hand flat, palm upwards, and the examiner’s hand holds the patient’s fingers. Test extension by asking the patient to stretch the thumb outwards, abduction by asking for the thumb to be pointed straight upwards, adduction by asking him or her to squeeze the examiner’s finger, and opposition by getting the patient to touch the little finger with the thumb. Look for limitation of these movements and discomfort caused by them. Next test metacarpophalangeal and interphalangeal movements. As a screening test, ask the patient to make a fist then to straighten out the fingers (Figure 9.19). Then test the fingers individually. If active flexion of one or more fingers is reduced, test the superficial and profundus flexor tendons (Figure 9.20). Hold the proximal finger joint extended and instruct the patient to bend it; the distal fingertip will flex if the flexor profundus is intact. Then hold the other fingers extended (to inactivate the profundus) and check finger flexion (inability indicates the superficialis is unable to work). The most common tendon ruptures are of the extensors of the fourth and fifth fingers.

Figure 9.17 (a) Active wrist extension and (b) active wrist flexion

Figure 9.18 Thumb movements

(a) Extension. (b) Abduction. (c) Adduction. (d) Opposition.

Figure 9.19 Screening metacarpophalangeal and interphalangeal movements

(a) Flexion. (b) Extension.

Figure 9.20 Testing the superficial and profundus flexor tendons

(a) Flexor profundus. (b) Flexor superficialis.

Function

It is important to test the function of the hand. Grip strength is tested by getting the patient to squeeze two of the examiner’s fingers. Even an angry patient will rarely cause pain if given only two fingers. Serial measurements of grip strength can be made by asking the patient to squeeze a partly inflated sphygmomanometer cuff and noting the pressure reached. Key grip (Figure 9.21) is the grip with which a key is held between the pulps of the thumb and forefinger. Ask the patient to hold this grip tightly and try to open up his or her fingers. Opposition strength (Figure 9.22) is where the patient opposes the thumb and individual fingers. The difficulty with which these can be forced apart is assessed. Finally, a practical test, such as asking the patient to undo a button or write with a pen, should be performed.

Figure 9.21 The key grip

Figure 9.22 Testing opposition strength

Tests of hand function should be completed by formally assessing for neurological changes (page 362).

Examination of the hands is not complete without feeling for the subcutaneous nodules of rheumatoid arthritis near the elbows (Figure 9.23). These are 0.5–3 cm firm, shotty, non-tender lumps which occur typically over the olecranon. They may be attached to bone. They are found in rheumatoid-factor-positive rheumatoid arthritis. Rheumatoid nodules are areas of fibrinoid necrosis with a characteristic histological appearance and are probably initiated by a small vessel vasculitis. They are localised by trauma but can occur elsewhere, especially attached to tendons, over pressure areas in the hands or feet, in the lung, pleura, myocardium or vocal cords. The combination of arthritis and nodules suggests the diagnostic possibilities listed in Table 9.11.

Figure 9.23 Subcutaneous nodules in rheumatoid arthritis

TABLE 9.11 Causes of arthritis plus nodules^*

^* Gouty tophi and xanthomata from hyperlipidaemia may cause confusion.

^† François Jaccoud (1830–1913), professor of medicine, Geneva.

Examination anatomy (Figure 9.24)

The humerus, radius and ulna meet at the elbow, which is a hinge and a pivot joint. Pivoting occurs between the radius and ulna, and the articulation between all three bones forms a hinge joint.

Figure 9.24 Anatomy of the elbows

History

Pain from the elbow is usually diffuse and may radiate down the forearm. It may occur over the lateral or medial epicondyle if the patient has tendinitis (tennis or golfer’s elbow). The patient may have noticed some swelling as a result of inflammation. Swelling over the back suggests olecranon bursitis. Stiffness may interfere with elbow movements and the patient may complain of difficulty combing the hair. When supination and pronation are affected the patient may complain of difficulty with carrying and holding. If the patient is aware of the elbow moving abnormally this suggests instability of the joint and may be a result of rheumatoid arthritis or trauma. Ulnar nerve trauma at the elbow may lead to a complaint of numbness or paraesthesiae in the distribution of that nerve.

Examination

Watch as the patient undresses, for difficulty disentangling the arms from clothing. The upper arms should be exposed completely. Note any deformity or difference in the normal 5–10 degree valgus position (carrying angle) as the patient stands with the palms facing forward.

Look for a joint effusion, which appears as a swelling on either side of the olecranon. Discrete swellings over the olecranon or over the proximal subcutaneous border of the ulna may be due to rheumatoid nodules, gouty tophi, an enlarged olecranon bursa or, rarely, to other types of nodules (Table 9.11).

Feel for tenderness, particularly over the lateral and medial epicondyles which may indicate tennis or golfer’s elbow, respectively. Palpate any discrete swellings. Rheumatoid nodules are quite hard, may be tender and are attached to underlying structures. Gouty tophi have a firm feeling and often appear yellow under the skin, but are sometimes difficult to distinguish from rheumatoid nodules. A fluid collection in the olecranon bursa is softly fluctuant and may be tender if inflammation is present. These collections are associated with rheumatoid arthritis and gout, but often occur independently of these diseases.

Small amounts of fluid or synovitis of the elbow joint may be detected by the examiner, facing the patient, placing the thumb of the opposite hand along the edge of the ulnar shaft just distal to the olecranon where the synovium is closest to the surface. Full extension of the elbow joint will cause a palpable bulge in this area if fluid is present.

Move the elbow joints passively. The elbow is a hinge joint. The zero position is when the arm is fully extended (0 degrees). Normal flexion is possible to 150 degrees. Limitation of extension is an early sign of synovitis.

If lateral epicondylitis is suspected, ask the patient to extend the wrist actively against resistance (see Figure 9.70, page 291). Test the range of active movements by standing in front of the patient and demonstrating. If there is any deformity or complaint of numbness, a neurological examination of the hand and arm are indicated for ulnar nerve entrapment.

Examination anatomy (Figure 9.25)

The shoulder joint includes the clavicle, scapula and humerus. The acromioclavicular joint is formed by the acromion of the scapula and the clavicle. Movements of the shoulder are a result of a combination of ball-and-socket articulation at the glenohumeral joint (between the glenoid cavity of the scapula and the ball-shaped end of the humerus) and motion between the scapula and the thorax. It is the most mobile joint in the body. The joint is encased in a capsule and is lined with synovium.

Figure 9.25 Examination of the shoulders

(a) Anatomy of the shoulder. (b) X-ray of left shoulder in the neutral position; the relative positions of the humeral head, clavicle and scapulae can be seen. (c) X-ray of left shoulder in abduction. Abduction of the arm rotates the head of the humerus and the clavicle moves upwards.

X-rays courtesy M Thomson, National Capital Diagnostic Imaging, Canberra.

This complicated joint is frequently affected by a number of non-arthritic conditions involving its bursa, capsule and surrounding tendons—e.g. ‘frozen (stiff) shoulder’ (adhesive capsulitis), tendinitis, bursitis. All of these disorders affect movement of the shoulder.

History

Pain is the most common symptom of a patient with shoulder problems.⁵ Typically it is felt over the front and lateral part of the joint. It may radiate to the insertion of the deltoid or even further. Pain felt over the top of the shoulder is more likely to come from the acromioclavicular joint or from the neck. Deformity has to be severe before it becomes obvious. Pain and stiffness may severely limit shoulder movement. Instability may cause the alarming feeling that the shoulder is jumping out of its socket. This is most likely to occur during abduction and external rotation (e.g. while attempting to serve a tennis ball). Loss of function may result in difficulty using the arms at above shoulder height or reaching around to the back.

Examination

Watch the patient undressing and note forward, backward and upward movements of the shoulders and whether these seem limited or cause the patient pain. Stand back and compare the two sides. The arms should be held at the same level and the outlines of the acromioclavicular joints should be the same. There may be wasting of one of the deltoid muscles that will not be obvious unless the two are compared.

Look at the joint. A swelling may be visible anteriorly, but unless effusions are large and the patient is thin these are difficult to detect. Look for asymmetry and for scars as a result of injury or previous surgery.

Feel for tenderness and swelling. Stand beside the patient, rest one hand on the shoulder and move the arm into different positions (see below). As the shoulder moves, feel the acromioclavicular joint and then move the hand along the clavicle to the sternoclavicular joint.

Move the joint (Figures 9.26 and 9.27). The zero position is with the arm hanging by the side of the body so that the palm faces forwards. Abduction tests glenohumeral abduction, which is normally possible to 90 degrees. For the right shoulder the examiner stands behind the patient resting the left hand on the patient’s shoulder, while the right hand abducts the elbow from the shoulder. Elevation is usually possible to 180 degrees when it is performed actively, as movement of the scapula is then included. Adduction is possible to 50 degrees. The arm is carried forwards across the front of the chest. External rotation is possible to 65 degrees. With the elbow bent to 90 degrees the arm is turned laterally as far as possible. Internal rotation is usually possible to 90 degrees. It is tested actively by asking the patient to place his or her hand behind the back and then to try to scratch the back as high up as possible with the thumb. Patients with rotator cuff problems complain of pain when they perform this manoeuvre. Flexion is possible to 180 degrees, of which the glenohumeral joint contributes about 90 degrees. Extension is possible to 65 degrees. The arm is swung backwards as in marching. During all these manoeuvres, limitation with or without pain and joint crepitus are assessed.

Figure 9.26 Movements of the shoulder joint

(a) Abduction using the glenohumeral joint. (b) Abduction using the glenohumeral joint and the scapula. (c) Extension. (d) Adduction.

Figure 9.27 Examining the shoulder joint

(a) Extension. (b) Flexion. (c) Apprehension test. (d) Internal rotation and abduction.

Rapid assessment of shoulder movement is possible using the three-step ‘Apley^j scratch test’ (Figure 9.28). Stand behind and ask the patient to scratch an imaginary itch over the opposite scapula, first by reaching over the opposite shoulder, next by reaching behind the neck and finally by reaching behind the back.

Figure 9.28 Apley scratch test to assess shoulder movements

The anterior stability of the shoulder joint is best assessed by the ‘apprehension’ test. Stand behind the patient, abduct, extend and externally rotate the shoulder (Figure 9.27c) while pushing the head of the humerus forwards with the thumb. The patient will strongly resist this manoeuvre if there is impending dislocation. There will be a similar response if the arm is adducted and internally rotated and posterior dislocation is about to occur.

This is also the time to test biceps function. The patient flexes the elbow against resistance. A ruptured biceps tendon causes the biceps muscle to roll up into a ball.

As a general rule, intra-articular disease produces painful limitation of movement in all directions, while tendinitis produces painful limitation of movement in one plane only, and tendon rupture or neurological lesions produce painless weakness. For example, if the abnormal sign is limited shoulder abduction in the middle range (45–135 degrees), this suggests ‘rotator cuff’ problems (i.e. the supraspinatus, infraspinatus, subscapularis and teres minor muscles) rather than arthritis.

In bicipital tendinitis there is localised tenderness on palpating over the groove. The supraspinatus tendon is a little higher, just under the anterior surface of the acromion. Supraspinatus tendinitis is common. Testing for it involves placing a finger over the head of the tendon while the shoulder is in extension. As this pushes the tendon forwards against the examiner’s finger, the movement is painful. When the shoulder is then flexed the tendon moves away and the pain disappears.

Don’t forget that arthritis affecting the acromioclavicular joint can be confused with glenohumeral disorders. Also remember to examine the neck and axillae in patients with shoulder pain.

History

The usual symptoms of temporomandibular joint dysfunction include clicking and pain on opening the mouth. The jaw may sometimes lock in the open position.

Examination

Look in front of the ear for swelling. Feel by placing a finger just in front of the ear while the patient opens and shuts the mouth (Figure 9.29). The head of the mandible is palpable as it slides forwards when the jaw is opened. Clicking and grating may be felt. This is sometimes associated with tenderness if the joint is involved in an inflammatory arthritis. Rheumatoid arthritis may affect the temporomandibular joint.

Figure 9.29 Examining the temporomandibular joints

Examination anatomy—the spine

The spinal column (Figure 9.30) is like a tower of bones that protects the spinal cord and houses its blood supply and efferent and afferent nerves. It provides mechanical support for the body and is flexible enough to allow bending and twisting movements. There are diarthrodial joints between the articular processes of the vertebral bodies, and the vertebral bodies are separated by the vertebral discs. These pads of cartilage are flexible enough to allow movement between the vertebrae. In the cervical spine from C3 to C7, the uncovertebral joints of Luschka^k are present. These are formed between a lateral bony extension (uncinate process) from the margin of the more inferior vertebral body with the one above. Osteoarthritic hypertrophy of these joints may result in pain or nerve root irritation.

Figure 9.30 (a) Structure of the spine (b) MRI scan of the lumbar spine showing the anatomical features seen in (a)

MRI scan courtesy M Thomson, National Capital Diagnostic Imaging, Canberra.

History

Pain is the most common neck symptom. Musculoskeletal neck pain usually arises in the structures at the back of the neck: the cervical spine, the splenius, semispinalis and trapezius muscles, or in the cervical nerves or nerve roots. Pain in the front of the neck may come from the oesophagus, trachea, thyroid gland or anterior neck muscles e.g. the sternocleidomastoid and platysma. Pain may be referred to the front of the neck from the heart.

There may be a history of trauma from direct injury or a sudden deceleration causing hyperextension of the neck; ‘whiplash’ injury. Injury can also be caused by attempted therapeutic neck manipulations by physiotherapists or chiropractors. The possibility of spinal cord injury must be considered in these patients. Ask about weakness or altered sensation in the arms and legs and any problem with bowel or bladder function.

The pain may have begun suddenly, suggesting a disc prolapse, or more gradually due to disc degeneration.

Postural tendon and muscle strains are common causes of temporary neck pain. These are often related to overuse. Ask for the patient’s occupation and whether work or recreational activities involve repeated and prolonged extension of the neck, e.g. painters and bicyclists. These patients often describe neck stiffness, and pain and muscle spasm are often present. The repeated holding of a telephone between the shoulder and the ear can cause nerve root problems. Neck movement may cause radicular symptoms such as paraesthesiae in the distribution of a cervical nerve after a hyperextension injury or cervical spine arthritis. Ask about paraesthesiae and weakness in the arms and hands.

Deformity may occur as a result of muscle spasm or sometimes following disc prolapse. Torticollis is a chronic and uncontrollable twisting of the neck to one side as a result of a muscle dystonia or cervical nerve root problem.

Examination

The patient should be undressed so as to expose the neck, shoulders and arms.

Look at the cervical spine while the patient is sitting up, and note particularly his or her posture (Figure 9.31). Movement should be tested actively. Flexion is tested by asking the patient to try to touch his or her chest with the chin (normal flexion is possible to 45 degrees). Extension (Figure 9.32a) is tested by asking the patient to look up and back (normally possible to 45 degrees). Lateral bending (Figure 9.32b) is tested by getting the patient to touch his or her shoulder with the ear; lateral bending is normally possible to 45 degrees. Rotation is tested by getting the patient to look over the shoulder to the right and then to the left. This is normally possible to 70 degrees.

Figure 9.31 Rheumatoid arthritis

Note the head tilt due to right atlanto-axial subluxation, the rheumatoid hands and the subcutaneous rheumatoid nodules.

Figure 9.32 Movements of the neck

(a) Extension—‘Look up and back’. (b) Lateral bending—‘Now touch your right ear onto your shoulder’ (45 degrees); rotation—‘Now look over your shoulder to the right and then to the left’ (70 degrees).

Feel the posterior spinous processes. This is often easiest to do when the patient lies prone with the chest supported by a pillow and the neck slightly flexed. The examiner should feel for tenderness and uneven spacing of the spinous processes. Tenderness of the facet joints will be elicited by feeling a finger’s breadth lateral to the middle line on each side (Figure 9.33).

Figure 9.33 Examining the spinous processes

Neurological examination of the upper limbs, including testing of shoulder abduction (C5, C6) and the serratus anterior muscle (C5, C6, C7), is part of the assessment of the neck.

History

Lower back pain is a very common symptom (Table 9.12). The discomfort is usually worst in the lumbosacral area. Ask whether the onset was sudden and associated with lifting or straining or whether it was gradual.^1,2 Stiffness and pain in the lower back that is worse in the morning is characteristic of an inflammatory spondyloarthropathy. Pain that shoots from the back into the buttock and thigh along the sciatic nerve distribution is called ‘sciatica’. In sciatic nerve compression at a lumbosacral nerve root, the pain is often aggravated by coughing or straining. ‘Lumbago’ however is often due to referred pain (e.g. from the vertebral joints). There may be other neurological symptoms in the legs due to nerve compression or irritation. The distribution of the paraesthesiae or weakness may indicate the level of spinal cord or nerve root abnormality. One should also ask about urinary incontinence and retention as well as numbness in the ‘saddle region’, erectile dysfunction and bowel incontinence, which can be a result of cauda equina involvement.

TABLE 9.12 Differential diagnoses for back pain

General inspection

Look to see whether the patient has a Cushingoid appearance due to steroid treatment (page 309), or whether there are signs of weight loss that may indicate active disease.

The hands

Put the hands on a pillow. Look especially for symmetrical small joint synovitis (the distal interphalangeal joints are usually spared). The other common abnormalities are ulnar deviation, volar subluxation of the metacarpophalangeal joints, and Z deformity of the thumb with swan neck and boutonnière deformity of the fingers. Examine the fingernails and periungual areas for splinter-like vasculitic changes and look for wasting of the small muscles of the hand. Look at the palms for palmar erythema. Feel the palms for palmar tendon crepitus while the patient extends and flexes the fingers. Look for signs of an ulnar nerve palsy (from ulnar nerve entrapment at the elbow) and a median nerve palsy (carpal tunnel).

The wrists

Look for synovial thickening and perform Phalen’s sign (carpal tunnel).

The elbows

Look around the elbows for rheumatoid nodules, which suggest seropositive disease, and examine the elbow joint. Flexion contractures are common.

The shoulders and axillae

Here examine for tenderness and limitation of movement. Also palpate the axillary nodes because enlarged nodes may indicate active disease of joints in the area that they drain.

The eyes

Look at the eyes for redness which may indicate the dryness of Sjögren’s syndrome (Table 9.8), which occurs in 10%–15% of cases. Note also nodular scleritis (an elevated white or purple-red lesion, which is pathologically a rheumatoid nodule and usually appears surrounded by the intense redness of the injected sclera) (Figure 9.50). These nodules occur especially in the superior parts of the sclera and are often bilateral, but affect only 1% of patients. Iritis does not occur.

Figure 9.50 Nodular scleritis involving the sclera lateral to the iris

With severe scleritis, scleral thinning may occur, exposing the underlying choroid. This is called scleromalacia. Look for cataracts due to steroid treatment. Conjunctival pallor may be present, indicating anaemia due to iron deficiency. This can be a result of blood loss from non-steroidal anti-inflammatory drug use, folate deficiency from a poor diet, hypersplenism or chronic inflammation, or some combination of these.

The parotids

Look for enlargement of the parotid glands, as occurs with Sjögren’s syndrome.

The mouth

Look for dryness of the mouth and dental caries (Sjögren’s syndrome), and ulcers related to drug treatment (e.g. methotrexate).

The temporomandibular joints

Feel the temporomandibular joints for crepitus as the patient opens and shuts the mouth.

The neck

Go on to examine the cervical spine for tenderness, muscle spasm and reduction of rotational movement. Examine for cervical lymphadenopathy.

The chest

Now examine the lungs for signs of pleural effusions or pulmonary fibrosis. Caplan’s syndrome^v is the presence of rheumatoid lung nodules in combination with pneumoconiosis.

The heart

Listen to the heart for a pericardial rub (relatively common) and for murmurs indicating valvular regurgitation (especially the aortic valve), which may occur due to nodular involvement of a heart valve.

The abdomen

Feel the abdomen for splenomegaly (this occurs in up to 10% of patients and suggests the possibility of Felty’s syndrome, page 229) and hepatomegaly. Feel the inguinal lymph nodes.

The lower limbs

Examine the hips for limitation of joint movement. The knees, however, are more often affected and here one must note any quadriceps wasting, synovial effusions and flexion contractures. Valgus deformity and ligamentous instability may occur as late complications. Look in the popliteal fossae for Baker’s cysts. Go on to look at the lower parts of the legs for ulceration; this can occur as a vasculitic complication of Felty’s syndrome. Examine for a stocking distribution peripheral neuropathy and for mononeuritis multiplex of the nerves of the lower limbs. There may also be signs of spinal cord compression due to anterior dislocation of the first cervical vertebra or vertical subluxation of the odontoid process.

The ankles and feet (Figures 9.47 and 9.48)

Now look for foot drop (peroneal nerve entrapment or vasculitis) and examine the ankle joint for limitation of movement. Look at the metatarsophalangeal joints for swelling and subluxation. There may also be lateral deviation and clawing of the toes. Remember that the interphalangeal joints are very rarely involved. Finally, feel the Achilles tendon for nodules—a sign of seropositive disease.

Ankylosing spondylitis

The following areas should be examined.

The back and sacroiliac joints: may show loss of lumbar lordosis and thoracic kyphosis; severe flexion deformity of the lumbar spine (rare); tenderness of the lumbar vertebrae; reduction of movement of the lumbar spine in all directions; and tenderness of the sacroiliac joints.

The legs: Achilles tendinitis; plantar fasciitis; signs of cauda equina compression (rare)—lower limb weakness, loss of sphincter control, saddle sensory loss.

The lungs: decreased chest expansion (less than 5 cm); signs of apical fibrosis.

The heart: signs of aortic regurgitation.

The eyes: acute iritis (tends to recur)—painful red eye (10%–15%) (Figure 9.51).

Figure 9.51 Iritis of the right eye

Rectal and stool examination: signs of inflammatory bowel disease (either ulcerative colitis or Crohn’s disease). Note: signs of secondary amyloidosis—for example, hepatosplenomegaly, renal enlargement, proteinuria—may be present, although this is a very rare complication.

X-rays of the spine and sacroiliac joints (Figure 9.52): may show ankylosis (fusion) of the sacroiliac joints and ‘squaring’ of the vertebral bodies as a result of loss of their anterior corners and periostitis of their waists. ‘Bridging syndesmophytes’^w occur as a result of ossification of the fibres of the joint annulus. Severe disease causes the changes called bamboo spine visible on X-ray.

Figure 9.52 Ankylosing spondylitis

Anteroposterior (a) and lateral (b) X-rays of the thoracic spine showing ankylosis of the sacroiliac joints, extensive syndesmophyte formation (short arrows) and squaring of the vertebral bodies (long arrows).

Courtesy Canberra Hospital X-ray library.

Reiter’s syndrome (reactive arthritis)

Classically this disease follows urethritis or diarrhoea, with conjunctivitis and arthritis (usually asymmetrical) of the large weightbearing joints such as the hip, knee or ankle. The following areas should be examined.

The genital region: urethral discharge; circinate balanitis—scaly, superficial reddened erosions with well-demarcated borders on the glans penis (Figure 9.53).

Figure 9.53 Circinate balanitis

The prostate: prostatitis.

The eyes: conjunctivitis; iritis (rare).

The mouth: painless smooth mucosal lesions, especially of the tongue.

The back: sacroiliac joints (may be unilaterally involved).

The lower limbs (more commonly affected): knees, ankles; metatarsophalangeal joints and toes (‘sausage toes’); plantar fasciitis, Achilles tendinitis; keratoderma blennorrhagica on the sole (non-tender reddish-brown macules, which become scaling papules; Figure 9.54)—this is indistinguishable from pustular psoriasis; nails thickened, opaque and brittle.

Figure 9.54 Reiter’s syndrome with keratoderma blennorrhagica

From FS McDonald, ed., Mayo Clinic images in internal medicine, with permission. © Mayo Clinic Scientific Press and CRC Press.

The hands (less commonly involved): wrists; metacarpophalangeal joints, proximal interphalangeal joints, distal interphalangeal joints; keratoderma blennorrhagica on the palms; nail changes.

Cardiovascular system: aortic regurgitation (rare).

X-ray findings: the first attack of arthritis is associated with soft-tissue changes and subsequent attacks may lead to joint-space narrowing and proliferative erosions at the joint margins. Changes in the sacroiliac joints and spine resemble those of ankylosing spondylitis except that the sacroiliac joint changes and spinal syndesmophytes tend to be asymmetrical. Calcaneal spurs (Figure 9.55)—a result of plantar fasciitis—are characteristic.

Figure 9.55 Reiter’s syndrome

X-ray of the pelvis of a patient with Reiter’s syndrome, showing loss of joint space in the sacroiliac joints (arrows).

Courtesy Canberra Hospital X-ray library.

Psoriatic arthritis

Ten per cent of patients with psoriasis (page 446) have arthritis.

Examine as for rheumatoid arthritis, but include the spine and sacroiliac joints. There are five distinct groups of psoriatic arthritis, but overlap is common.

X-ray findings (Figure 9.56): in mild cases X-rays are normal or show only joint-space narrowing and erosive changes. Unlike the X-rays of rheumatoid joints the bone density is maintained and there may be sclerotic changes in the small bones. Ankylosis of peripheral joints and arthritis mutilans can occur in either condition. The involvement of the spine and sacroiliac joints is asymmetrical, as in Reiter’s syndrome.

Figure 9.56 Psoriatic arthritis

X-ray of the wrist of a patient with psoriatic arthritis; note the ‘pencil in cup’ deformity (tapered proximal osseous surface and expanded base) of the distal bone of the fingers, early ankylosis [arrowhead] of the proximal interphalangeal joint of the right little finger and erosions with proliferative change of the little finger). Note also the lack of osteoporosis.

Courtesy Canberra Hospital X-ray library.

Enteropathic arthritis

There are two patterns of involvement of the joints with ulcerative colitis and Crohn’s disease.

General inspection

Look for weight loss (due to chronic inflammation) or a Cushingoid appearance (steroid treatment). While taking the history note any abnormal mental state—psychosis may occur due to the lupus itself or to steroid therapy.

Hands

Note any vasculitic-appearing lesions around the nail bed, or telangiectasia and erythema of the skin of the nail base. A rash may occur—photosensitivity is common. The hand rash of lupus tends to occur over the phalanges, as opposed to that of dermatomyositis which affects the knuckles.

Raynaud’s phenomenon may occur if the weather is cold (Table 9.7).

Examine for arthropathy: synovitis of the proximal and metacarpophalangeal joints. The arthritis of SLE is not erosive, but if severe may lead to reducible deformities due to damage to supporting structures.

Forearms

Livedo reticularis may occur here; in Latin this describes skin discoloration in the form of a small net. This is formed by connected bluish-purple streaks without discrete borders. They occur usually on the limbs and are associated with various connective tissue diseases.¹¹ Look for purpura (due to vasculitis¹² or autoimmune thrombocytopenia). Examine for a proximal myopathy (due to the disease itself or to steroid treatment). Subcutaneous nodules very rarely occur in SLE. The axillary nodes may be enlarged but will not be tender.

The head and neck

Alopecia (hair loss) is an important diagnostic clue that occurs in about two-thirds of patients and may be associated with scarring. Look especially for lupus hairs, which are short, broken hairs above the forehead. The hair as a whole may be coarse and dry, as in hypothyroidism.

Examine the eyes for scleritis and episcleritis (see Figure 9.50). The eyes may be red and dry (Sjögren’s syndrome). Pallor of the conjunctivae occurs with anaemia, usually due to chronic disease. Occasionally jaundice due to autoimmune haemolytic anaemia may be found. Perform a fundoscopy for cytoid bodies, which are hard exudates (white spots) due to aggregates of swollen nerve fibres and are secondary to vasculitis.

A facial rash may be diagnostic (Figure 9.61). The classical rash is an erythematous ‘butterfly rash’ over the cheeks and bridge of the nose and must be distinguished from rosacea. Mouth ulcers on the soft or hard palate may occur and the mouth may be dry (Sjögren’s syndrome).

Figure 9.61 Butterfly rash of systemic lupus erythematosus

The rash of discoid lupus may be found in the same area or affect different parts of the body. Lesions begin as spreading red plaques which have a central area of hyperkeratosis and follicular plugging. An active lesion has an oedematous edge. The appearance may suggest psoriasis. A healed lesion may have marginal hyperpigmentation with central atrophy and depigmentation. The scalp, external ear and face are most commonly affected, but in some patients lesions may occur all over the arms and chest. Extensive annular or psoriaform lesions may indicate the presence of subacute cutaneous lupus.

After examining the face, feel for cervical lymphadenopathy, which is usually non-tender.

The chest

Signs of a pericardial rub (from pericarditis) may be found. In the respiratory examination a pleural rub (pleuritis) or signs suggesting the presence of a pleural effusion, pulmonary fibrosis, pulmonary collapse or pulmonary hypertension may be detected. Chest disease is probably most often secondary to an interstitial pneumonitis rather than to vasculitis of the lungs.

The abdomen

Splenomegaly, usually mild, can be detected in 10% of cases. Hepatomegaly (mild) may occur in uncomplicated cases. Chronic liver disease due to chronic hepatitis (‘lupoid hepatitis’) is a separate autoimmune disease rather than a variant of SLE.

The hips

Examine the hip joint movements: in aseptic (avascular) necrosis there is pain on movement, with preservation of hip extension but loss of the other movements. This is due to ischaemia of the femoral head and may be related to steroid use or to the SLE itself.

The legs

Examine for proximal myopathy and peripheral neuropathy (mainly sensory).

Rarely there may be signs of hemiplegia, cerebellar ataxia or chorea.

Leg ulceration over the malleoli, due to vasculitis or the antiphospholipid syndrome,¹¹ is important. Very occasionally the toes may be gangrenous. There may be ankle oedema from the nephrotic syndrome or fluid retention from steroids. Livedo reticularis may be present on the legs.

Urine and blood pressure

Perform a urine analysis (for proteinuria and haematuria) and take the blood pressure (for hypertension). Renal disease is a common complication of SLE.

Temperature

Take the temperature, as fever is common in SLE, either from secondary infection or from the disease per se.

General inspection (Figure 9.62)

Look for cachexia due to dysphagia (from an oesophageal motility disturbance) or malabsorption (due to bacterial overgrowth).

Figure 9.62 Scleroderma

1. General appearance

‘Bird-like’ facies

Weight-loss (malabsorption)

1. Hands

CRST—calcinosis, atrophy distal tissue pulp (Raynaud’s), sclerodactyly, telangiectasia

Dilated capillary loops (nailfolds)

Small-joint arthropathy and tendon crepitus

Fixed flexion deformity

Hand function

3. Arms

Oedema (early), or skin thickening and tightening

Pigmentation

Vitiligo

Hair loss

Proximal myopathy

4. Head

Alopecia

Eyes—loss of eyebrows, anaemia, difficulty with closing

Mouth—puckered, difficulty with opening

Pigmentation

Telangiectasia

Neck muscles—wasting and weakness

5. Dysphagia

6. Chest

Tight skin (‘Roman breastplate’)

Heart—cor pulmonale, pericarditis, failure

Lungs—fibrosis, reflux pneumonitis, chest infections

7. Legs

Skin lesions

Vasculitis

8. Other

Blood pressure (hypertension with renal involvement)

Urine analysis (proteinuria)

Temperature chart (infection)

Stool examination (steatorrhoea)

Skin changes in scleroderma vary. There may be an early oedematous phase with non-tender pitting oedema of the hands which appear tightly swollen. In patients with progressive disease the oedematous skin is replaced by indurated skin which appears thickened, hard and tight. This phase usually begins in the fingers (Table 9.17).

TABLE 9.17 Differential diagnosis of thickened tethered skin

The hands

Examine the hands. Note particularly calcinosis (palpable nodules due to calcific deposits in the subcutaneous tissue of the fingers), Raynaud’s phenomenon sometimes causing atrophy of the finger pulps (due to ischaemia) (Figure 9.63), sclerodactyly (tightening of the skin of the fingers leading to tapering), and multiple large telangiectasia on the fingers (Figure 9.64).

Figure 9.63 Digital infarcts

Figure 9.64 Telangiectasia of the hands in the CREST syndrome

Look for contraction deformity of the fingers, which is relatively common (Figure 9.65), and for synovitis, although this is uncommon. The nails can be affected by Raynaud’s. It can be useful to inspect the nailfolds using a hand-held magnifying glass: in scleroderma you may see dilated capillary loops but this is not diagnostic. These are best viewed on the fourth digit. Assessing hand function is important in this disease.

Figure 9.65 Systemic sclerosis: signs in the hands

Sclerodactyly, tethered smooth skin, calcinosis and ulceration, atrophy of finger pulps due to Raynaud’s phenomenon, and fixed flexion deformities of the fingers.

The arms

Determine the extent of skin tethering in the arms. If the skin thickening extends above the wrists to the arms, legs or trunk, the diagnosis is diffuse scleroderma rather than CREST. If the skin thickening extends only to the elbows and face this is called limited scleroderma. Assess for proximal myopathy due to myositis.

The face

The skin of the face is involved in progressive disease. There is loss of normal wrinkles and skinfolds as well as of the eyebrows. The face appears pinched and expressionless (‘bird-like’ facies). Inspect for malar telangiectasia and look for salt-and-pepper pigmentation. Ask the patient to close the eyes—skin tethering may make this incomplete. The eyes may be dry (Sjögren’s syndrome), though this is uncommon, and the conjunctivae pale (there are a number of reasons for anaemia, including the presence of chronic disease, bleeding from oesophagitis, watermelon stomach and microangiopathic haemolytic anaemia).

Ask the patient to open the mouth fully. It may appear puckered and narrow. Inability to open the mouth so that there is more than 3 cm of clearance between the incisors indicates abnormal restriction.

The chest

Inspect the skin of the chest wall, which may have acquired a tight, thickened appearance, like ancient Roman breastplate armour.

Examine the lungs for pulmonary fibrosis, evidence of reflux pneumonitis, or (rarely) a pleural effusion or alveolar cell carcinoma.

Examine the heart for cor pulmonale secondary to pulmonary fibrosis or for pericarditis. Left ventricular failure may also occur due to myocardial involvement.

The legs

Look for signs of vasculitis, ulceration and skin involvement. Peripheral neuropathy is rare.

Urinalysis and blood pressure

These are very important because renal involvement is common in scleroderma and is often associated with severe hypertension. Renal disease is one of the most common causes of death.

The stool

Look for evidence of steatorrhoea (due to malabsorption from bacterial overgrowth). A summary of the physical signs that can be found in scleroderma is presented in Figure 9.62.

Examining the patient with suspected rheumatic fever

First examine the large joints of the limbs for effusions and synovitis. Two or more joints must be involved (classically there is a transient migratory polyarthritis). Feel for subcutaneous nodules over bony prominences. Look for a rash. Erythema marginatum is a slightly raised pink or red rash that blanches with pressure. The red rings have a clear centre and round margins, and occur on the trunk and proximal limbs; the rash is not found on the face. Look for choreiform movements. Their onset is usually delayed until about 3 months after the throat infection.

Now examine the cardiovascular system for any signs of pancarditis: (i) a pericardial rub due to pericarditis; (ii) congestive cardiac failure due to myocarditis; (iii) mitral or aortic regurgitation due to acute endocarditis.

Finally, take the temperature.

Fibromyalgia syndrome

This syndrome is a common, frequently overlooked condition that mostly affects women in their 40s and 50s. It presents with a variable group of symptoms including widespread musculoskeletal aches and pains, and usually with symptoms of chronic fatigue. The musculoskeletal pain is mostly axial (neck and back) and diffuse. It is made worse by stress or cold. Pain may be felt ‘all over’ and is unresponsive to anti-inflammatory drug treatment. The combination of pain and fatigue may cause the patient severe disability. There is usually a poor sleep pattern. The patient wakes up not feeling refreshed, and more tired in the morning than later in the day. Note that no abnormal pathology has been found in the joints, muscles or tendons of these patients.

Examination

Test for the characteristic multiple hyperalgesic tender points (Figure 9.66). These areas may be tender to finger pressure in normal people but in affected patients there is marked tenderness and a definite withdrawal response. This response should be obtained in at least 11 of 18 sites in the upper and lower limbs and on both sides (i.e. it is widespread and symmetrical). Next examine for hyperalgesia at control sites such as the forehead or distal forearm, where it should be absent.

Figure 9.66 Frequent sites of localised tenderness in fibromyalgia

18 tender point sites (test bilaterally) are:

1. Insertion of suboccipital muscle

2. Under lower sternocleidomastoid muscle

3. Insertion of supraspinatus muscle

4. Trapezius muscle (mid upper)

5. Near second costochondral junction

6. 2 cm distal to lateral epicondyle

7. At prominence of greater trochanter

8. Upper outer quadrant of buttock

9. At medial fat pad of knee

The diagnosis is based on the presence of typical symptoms and multiple hyperalgesic tender sites (with negative control sites). Inflammatory and endocrine disease must be excluded.

Frozen shoulder

Capsulitis of the shoulder, or frozen shoulder, is associated with limitation of active and passive arm movements in all directions. It may follow immobilisation of the arm after a stroke. There is typically a sudden onset of shoulder pain, which is worse at night and radiates to the base of the neck and down the arm. Pain is made worse by shoulder movement and may be bilateral. Pain and stiffness usually subside over a period of months. Complete movement may not be regained.

Elbow epicondylitis (tennis and golfer’s elbow)

Many contact and non-contact sports can cause physical injury, although serious injuries are rather uncommon with certain sports (e.g. synchronised swimming). There may be pain over the epicondyles of the elbow. The lateral epicondyle is the most often affected and is called ‘tennis elbow’. Pain arises from the site of insertion of the extensor muscle tendons into the lateral epicondyle (enthesis). Involvement of the medial epicondyle at the site of insertion of the flexor tendons of the forearm causes medial epicondylitis—‘golfer’s elbow’. These conditions are also common in manual workers such as painters.

Examination

Examine for local tenderness over the lateral (Figure 9.68) or medial epicondyle (Figure 9.69). Ask the patient to extend the fingers against resistance (Figure 9.70). This will make the pain of lateral epicondylitis worse. Ask the patient to flex the fingers against resistance. This will exacerbate the pain of medial epicondylitis.

Figure 9.68 Examination of the elbow

Looking for signs of lateral epicondylitis. Palpation over the forearm extensor muscle origin elicits pain. Straining the muscles by resisted extension of the wrist exacerbates the symptoms.

Figure 9.69 Examination to elicit signs of medial epicondylitis

Local pressure over the medial epicondyle elicits pain. Symptoms are exacerbated by resisted flexion of the wrist and fingers.

Figure 9.70 Testing for lateral epicondylitis

Tenosynovitis of the wrist

Inflammation of the synovial tubes in which tendons run can occur in patients with rheumatoid arthritis but also in otherwise healthy people. The cause is often unaccustomed repetitive movement. A common site for tenosynovitis is at the wrist, where it involves the long extensor and abductor tendons of the thumb (de Quervain’s tenosynovitis; Figure 9.71).

Figure 9.71 A patient with de Quervain’s tenosynovitis

There is characteristic swelling of the tendon sheath of the abductor pollicis brevis over the styloid process of the radius.

Examination

This reveals tenderness and swelling on the radial side of the wrist (radial styloid). There is pain on active or passive movement of the thumb. Confirm the diagnosis by performing Finkelstein’s test.^z Hold the patient’s hand with the thumb tucked into the palm and then quickly turn the wrist into full ulnar deviation (Figure 9.72). An alternative approach that is reported to produce fewer false-positives involves gripping the patient’s thumb rather than tucking the thumb into the palm.¹³ Sharp pain will occur in the tendon sheath when the test is positive. Examine also the other common sites of tendon involvement—the flexor tendons of the fingers and the Achilles tendon.

Figure 9.72 Finkelstein’s test

Bursitis

Bursae are found in areas exposed to mechanical strain or trauma, either at the site where muscle or tendon glides over bone or muscle, or superficially where bony prominences are exposed to mechanical stress. Bursitis usually occurs as a local soft-tissue inflammatory reaction to unusual mechanical pressure. It may be associated with rheumatoid arthritis, gout or sepsis. Common sites include the prepatellar area (housemaid’s knee) (Figure 9.73), over the olecranon (olecranon bursitis) and over the greater trochanter (trochanteric bursitis).

Figure 9.73 A red, swollen and painful prepatellar bursa

(a) Anterior view. (b) Lateral view.

Carpal tunnel syndrome

Compression of the median nerve at the wrist is the most frequent form. This seems hardly surprising when one remembers that the carpal tunnel, sandwiched between the carpal bones and the carpal ligament, contains 9 flexor tendons as well as the median nerve. These patients complain of numbness and paraesthesiae in the median nerve distribution (the 3 radial fingers and the radial side of the ring finger). Symptoms often wake patients from sleep and may radiate up the forearm (one-third of cases). The commonest cause is an overuse tenosynovitis of the flexor tendon sheaths at the wrist. Fluid retention during pregnancy or from use of the oral contraceptive pill can also produce carpal tunnel symptoms. In addition, median nerve compression can occur in rheumatoid arthritis, hypothyroidism, acromegaly and amyloidosis.

Meralgia^aa paraesthetica

Compression of the lateral cutaneous nerve of the thigh causes paraesthesiae and sensory loss over the lateral side of the thigh (page 375). This entirely sensory nerve passes through the lateral part of the inguinal ligament only just medial to the anterior superior iliac spine. Here it is subject to compression in patients who are obese, wear tight or heavy belts or spend long periods sitting. Diabetes, pregnancy and trauma can also be causes of problems with the nerve.

Tarsal tunnel syndrome

This may be caused by compression of the posterior tibial nerve in its fibro-osseous canal formed by the flexor retinaculum and the tarsal bones. Symptoms include burning pain and paraesthesiae in toe, sole and heel. Patients are often woken with pain at night and, as with the carpal tunnel syndrome, this may radiate upwards. Walking may improve the symptoms. Causes include diabetes, synovitis from rheumatoid arthritis, bony deformity and flexor tenosynovitis. Hypertrophy of the abductor hallucis muscle, which occurs in intemperate runners, is an occasional cause.

Morton’s ‘neuroma’

This is caused by compression of one or more of the interdigital plantar nerves by the transverse metatarsal ligament. Patients complain of a burning pain or ache that extends distally from the affected web space to the toes (most often the third and fourth).

Metatarsalgia is a non-localised ache that spreads across the forefoot involving the area of some or all of the metatarsal heads. It can occur in normal feet after prolonged standing but also occurs in a number of other foot conditions (Table 9.19), and is often associated with poor-fitting shoes. Morton’s metatarsalgia is interdigital nerve entrapment (usually between the third and fourth metatarsal bones. Patients describe burning pain between the metatarsal bones and may have numbness on the adjacent toes. They get relief by removing their shoes and massaging the foot.

TABLE 9.19 Causes of metatarsalgia